The Michigan Stroke Network: 18 Months and Counting

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The Michigan Stroke Network 18 Months and
Counting

• Richard D. Fessler, M.D.
• Medical Director
• Michigan Stroke Network

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Thanks to!

• Jack Weiner
• Robert Fisher
• Joseph Bander
• Connie Parliament
• Amy Wright
• Karrie Landry
• Mary Jo Malafa
• Trinity Health

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Disclosures
I have no financial interest in any entity
discussed in this presentation. Consultation
Agreements Boston Scientific Corp. EV3 Advisory
Board In Touch Health Research ISSYS
Corporation
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Recent data

• 1997-2005
• Hospitalizations for ischemic stroke declined by
  one-third.
• 2005
• 892,000 hospitalizations for cerebrovascular
  disease
• 46.2 ischemic stroke
• 12.8 hemorrhagic stroke
• 36 Transient ischemic attack, stenosis and
  occlusion of precerebral arteries

AHRQ Reports 05/09/2008
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Recent data

• Hospitalizations for cerebrovascular disease
• 8.5 billion
• 3 of total cost associated with hospital
  inpatient care
• ALOS
• Hemorrhagic stroke 8.4 days/19,500
• Ischemic stroke 5.6 days/9,100
• TIA/Stenosis/Occ 2.5 days/8,000

AHRQ Reports 05/09/2008
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Recent data

• Cerebrovascular Disease
• More likely than any other condition
• To present through the ER
• To be discharged to NH or Rehab facility
• To have a higher rate of mortality than other
  conditions
• Hemorrhagic stroke 25.1
• Ischemic stroke 5.9

AHRQ Reports 05/09/2008
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The Michigan Stroke Network
A mission-driven program to enhance stroke care
within the state of Michigan

• The Idea
• Impact stroke care at the access point
• Redefine the typical relationship in a referral
  network
• The Model
• RPRs
• Algorithms
• Education and Contact
• The Results
• Calls
• Interventions

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The MSN Idea

• Approximately 1 of all eligible stroke patients
  receive IV tpa
• Less than 2 of eligible stroke patients receive
  IV tpa at high volume centers
• How to improve?

Annals of Emergency Medicine, 2007
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The MSN Idea

• Issues associated with delayed stroke care
• Time to hospital
• Time to diagnosis
• Finite window for intervention
• Lack of on-site expertise
• Lack of infrastructure
• Resources
• Tpa
• Personnel
• Critical care
• transfer

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The MSN Idea

• Bring expertise to the access point
• 24/7 availability of stroke experts
• Encourage local expertise
• Support local JCAHO stroke certification
• Make available algorithms for care
• www.michiganstrokenetwork.org
• Assist in evaluation and triage of potential
  stroke victims

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The MSN Idea

• Rapidly triage patients in need of tertiary care
• Tpa failures
• High NIHSS scores
• gt 3 hours
• Critically ill patients at CAHs

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The MSN Model

• Provide 24/7 access to stroke experts
• 1.866.522.8MSN (8676)
• Accomplished using remote presence robots (RPRs)
• Rapid transfer as necessary via med-flight

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The MSN Model

• Ready access to treatment algorithms
  www.michiganstrokenetwork.org
• General care/evaluation
• Tpa inclusion/exclusion
• Consent forms
• BP management

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The MSN Model

• Rapid Transport
• MSN has contracted 3 medical flight companies
  within Michigan.
• Fixed wing and helicoptor services
• Sites are from 10-227 miles from Hub
• Air transport time ranges from 3 to 89

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The MSN Model

• Access to Tertiary Care
• SJMO is Hub of MSN
• 24/7 access to stroke expertise
• 24/7 access to neuroendovascular specialists
• Access to study protocols to increase the
  potential treatment window
• ALIAS
• 5
• Access to technology to increase treatment window
• MERCI Retriever
• 8
• Access to HDE protocols
• Wingspan Stent System

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The MSN Model

• Communication
• RPR contact with sites
• Follow-up
• Letter to center within 1 business day regarding
  contact with MSN
• Interaction and Collegiality
• Discharge coordination with facility near home
• Inpatient rehab transfers
• Primary care follow-up at home
• Education
• Site contact, nurse CEUs
• Process instruction

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The MSN Results
Michigan Stroke Network Participating
Hospitals July 2008
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The MSN Results2006/7 vs. 2008
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MSN Results
06/7 vs 08
Calls vs. transfers
30
118
tpa
83.3
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Site Arrival/MSN Contact/tpa needle time
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Transfers vs. Cath Lab
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323
592
640
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The Ripple Effect
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MSN Conclusions

• The Michigan Stroke Network
• Provides an opportunity to provide care to an
  underserved population
• Provides ready access to specialists for
  participating hospitals
• Utilizing the MSN, tpa is delivered 40 to 60
  times the national average.